Medullary Sponge Kidney Questionnaire

Name *:
Country *:
Age *:
Gender :Male Female
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Q1: Are you the patient with Medullary Sponge Kidney (MSK)?
Yes No, a friend or family member has MSK
Q2: Is there any family history of MSK?
Yes No, Not clear
Q3: How long has it been since the patient was first diagnosed?
Less than 3 months 3-6 months 6 months to one year 1-3 years 5-10 years over 10 years
Q4: Choose if the patient has any of the following symptoms/discomforts
Burning or painful urination Pain in the back lower abdomen or groin Difficulty in urination Cloudy dark or bloody urine Foul-smelling urine Fever and chills Hypercalciuria Vomiting Kidney stones Urinary tract infections
Renal Insufficiency
Others
Q5: Do you know the current glomerular filtration rate (GFR), or kidney function now?
90-120ml/min/1.73 m2 60-90ml/min/1.73m2 15-60ml/min/1.73m2 Below 15ml/min/1.73m2 Not sure
Q6: What about the patient's serum creatinine level now?
0.5-1.2mg/dl 1.2-2.0mg/dl 2.0-4.0mg/dl 4.0-5.0mg/dl Above 5.0mg/dl Not clear
Q7: Choose if you have any of the following concerned questions
Prevention and early detection of MSK Prevention or treatment for kidney stones and infections caused by MSK Daily nursing care for MSK Detailed analysis of the specific illness condition Nursing care and dietary plan for MSK
Summary: Write down any detail you feel pertinent to the illness condition, or add any other information you want to be provided with.
 

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